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case inpoint
December 2008/January 2009

Coordinating Care, Changing Lives

Doctors are often reluctant to diagnose young children with chronic diseases like asthma. But through intervention, parents are better prepared to manage symptoms.

IN THE Young


10 million diagnosed children under the age of 18. 5,600 reported deaths. 12 million asthma attacks. More than 1 million hospitalizations. 2 million emergency room visits. 13 million missed school days. $19.7 billion loss in health care and productivity costs.

sthma, the most common chronic childrens disease, affects an average of one in 13 school-aged children, according to the Centers for Disease Control and Prevention (CDC). A chronic inflammatory disorder with attacks ranging from mild to life-threatening, its symptoms include shortness of breath, coughing, wheezing and chest pain. Asthma can limit activity and affect a childs overall well-being. It can also place a significant financial and emotional burden on the family.The number of new cases, hospitalization visits, and deaths from asthma has increased dramatically over the last 20 years. While these statistics are staggering, with proper planning and education, children and their parents can manage their asthma and learn to breathe easier.

Asthma Management
Doctors are often reluctant to diagnose young children with chronic diseases like asthma. But through intervention, parents are better prepared to manage symptoms.
December/January 2009

Reprinted with permission from Case In Point Magazine All rights reserved 2009

The goal is to identify asthma triggers, remove life barriers, and motivate healthy behaviors, including medication adherence and self-monitoring of symptoms. One way to control attacks and symptoms is to identify and avoid environmental triggers such as: Dust. Pollution. Stress. Household products (aerosol sprays, cleaning solutions, paint). Smoke (cigarettes, pipes or cigars, wood-burning stoves, fireplaces, charcoal cooking). Infections, colds, upper airway congestion, sinus drainage and sore throat. Allergies (animals, insects, foods, pollens). Life challenges can get in the way of health. Issues like language barriers or low literacy can often cause confusion about medical advice or prescription guidelines. Parental behaviors are also important to address early. For example, smoking in the home and car can greatly aggravate a childs symptoms. Knowing the triggers, barriers and behaviors is a critical way to gain and maintain control of asthma.

The National Institutes of Healths evidence-based guidelines provide a serviceable template for the diagnosis and treatment of asthma:
1. Measures of assessment and monitoring Obtained by objective tests, physical examination, patient history and patient report. Diagnose and assess the characteristics and severity of asthma Monitor response, i.e., whether asthma control is achieved and maintained. 2.Education for a partnership in asthma care Provide patients with the skills necessary to control asthma and improve outcomes. Asthma self-management education should be integrated into all aspects of asthma care, and it requires repetition and reinforcement. 3.Control of environmental factors and co-morbid conditions that affect asthma Evaluate the role of allergens and irritants, particularly indoor inhalant allergens. 4.Pharmacologic therapy Stepwise approach. The type, amount and scheduling of medication is dictated by asthma severity for initiating therapy. Level of asthma control for adjusting therapy. Step-down therapy (after three months) is essential to identify the minimum medication necessary to maintain control.

Motivating Healthy Behaviors

The health of a child is not a one size fits all proposition. At Nurtur, a wellness company with a track record of asthma management, including the rare tradition of addressing asthma in children as young as newborns, health coaches play a prominent role in the administration of care.This is yet another area where statistics show that the use of a health coach can return favorable outcomes. A key, first step is to incorporate the unique needs, which range from the cultural to the socioeconomic. Health coaches go through motivational interview training to learn techniques, such as asking open-ended questions and exploring readiness to change.This background information helps health coaches effectively assess the individual members needs. For Nurtur, which is a subsidiary of the Centene Corporation, its approach is based on an inclusive people-centered model and coaching method designed to understand the person in toto.

D e c e m b e r / J a n u a ry 2009

Reprinted with permission from Case In Point Magazine All rights reserved 2009


Giving a Child

etty Simonton is a bilingual health coach at Nurtur. Her work with one family provides insight into the effectiveness of the design process that enables members to take control of their asthma. Letty began working with an 8-year-old member and her mother from Texas in May 2007. During the baseline call, the mother reported that her daughter did not exhibit problems with her breathing. She thought her childs asthma only flared up when she got sick. As the conversation continued, Letty learned that the girl had been to the emergency room twice over the past year and had missed four days from school for her flare-ups. After more probing, the mother said her daughter was coughing after playing and occasionally waking during the night as well. It was clear that the mother was unaware that all of these symptoms were directly related to her daughters asthma. Aside from a lack of general asthma education, there were also challenges with language, medication compliance and socioeconomic barriers. The mother spoke very little English and didnt understand the importance of using the correct medicine. The child was prescribed an albuterol inhaler for use as needed, but instead she gave her a breathing treatment with her sons nebulizer. Letty felt that it would be beneficial to visit the member and her mother in their home. The little girl lived with her parents in a mobile home in a rural area. An environmental assessment of the home was then completed, triggers were identified, and an action plan was developed. Letty made sure they understood the triggers, the medication doses, and the importance of visiting their doctor regularly. As of April 2008, the child has no hospital or emergency room visits, and is on a medication regimen that has her asthma under control. Now she has a nebulizer of her own, an albuterol inhaler for home and school use, and she knows her personal best peak flow number and monitors her own asthma. She reported waking up less than one night per week, and her mother is now much more comfortable speaking with the childs physician. cip

Assessing Outcomes
With innovative asthma management programs, children with asthma can attend school on a regular basis, participate in physical activities, and avoid the emergency room. Consider the following outcomes achieved by Nurtur, as reported by members who had been enlisted in the program for at least 90 days: 46 percent fewer asthma attacks. 69 percent decrease in hospital admissions. 60 percent decrease in emergency room visits. 36 percent fewer missed school days. 62 percent fewer missed days of work. Members nearly four times (376 percent increase) more likely to use a peak flow meter after participation. Patient education, including a written action plan to guide self-management at home, is the underlying key for success. Not only does this encourage healthy behaviors, but it also improves productivity and reduces health care costs.

Reprinted with permission from Case In Point Magazine All rights reserved 2009

December/January 2009

Respiratory therapists guide patients toward open, healthy passageways


Editor in Chief Anne Llewellyn sat down with Judy Topolsky, the client service director at Centene Corporation, parent company of the wellness subsidiary Nurtur, to talk about the benefits of health coaching.


Anne Llewellyn: What model of health coaching do you utilize in the asthma disease management program?
Judy Topolsky:We utilize a people-centered approach to health coaching, and we use member engagement and motivational-interviewing techniques to accomplish this. Nurturs health management programs are unparalleled in the comprehensiveness of the participant assessment, the percentage of participants actively counseled, and the breadth and depth of counseling.
D e c e m b e r / J a n u a ry 2009

Each participant is assigned a personal health coach who remains the participants primary point of contact throughout the programs duration. Primary health coaches and participants develop close bonds that keep the participants engaged as they become educated and motivated to reduce their risk factors and develop health behaviors. Participants learn to stick to an exercise program and make healthy dietary choices. They quit smoking successfully.They learn how and why their drug therapies work and about the importance of medication compliance.

Reprinted with permission from Case In Point Magazine All rights reserved 2009

Over time, through gradual, attainable achievements, participants develop the knowledge, skills and self-discipline to reduce their risks and self-manage their disease each day. Our health coaches are trained in health coaching techniques that empower and motivate participants by advancing their willingness to change. It is a patient-centered approach that works with the participants agenda for change, rather than the health coachs. Participants at any stage of change can be coached to resolve their ambivalence to change and to explore issues surrounding their chronic condition rather than have change dictated to them by counselors. AL: Can you talk about specific ways you achieve an intervention? JT: Elements of effective motivational intervention include: Convey an acceptance and understanding of the members feelings.This is considered the most powerful tool to promote behavior change. Recognize and effectively dissuade resistance. Avoid conversational roadblocks, listen empathetically, and exercise reflective listening skills as a means to roll with resistance. Guide the member to realize that a discrepancy exists.This counseling style allows the member to intrinsically reach an understanding that current health behaviors are not conducive to achieving health goals. Foster and enhance self-efficacy. Confidence in the ability to successfully change a health-related behavior will greatly improve the members success. AL: What value do health coaches bring to the population being managed? JT: We really focus our efforts on behavior change and starting with the member wherever they are on taking care of themselves and their disease.We target our education and efforts on the issues that are most important to the member at the time. cians to assist with getting medications and transportation to physician visits. Nurtur works with health plans to obtain transportation services. Pediatric members have difficulty with school nurses allowing the child to use rescue medications. Nurtur contacts and arranges in-person education sessions with individual school nurses regarding asthma education. Housing, electricity and meals are all issues that Nurtur works directly with health plan case management to resolve. Environmental assessments are conducted by Nurtur field health coaches and recommendations are made to decrease environmental triggers. Utilizing bilingual therapists and interpreters helps remove language barriers. AL: How have physicians reacted to your model? JT: Overall, we have had good response from the physician community.The medication list on the treatment plan has been invaluable to inform the physician about all medications that members are using and how they are using them.Teaching peak flow meter use and actually providing peak flow meters is another area that physicians are happy about.We also use a provider relations specialist, who is a respiratory therapist. He goes out to the PCP offices and meets with them to help explain the program. AL: What tips have you and your team learned about working collaboratively with physicians that you can pass onto your case management colleagues? JT: I think that case management has been very helpful in establishing relationships with many physicians, and usually they have all of the great tips for us. Again, it has been most helpful for us to go out to the physician and help him and the office staff to understand what our program does and how we can help. AL: What other disease states does your team manage? JT: COPD, diabetes, heart failure, CAD and tobacco cessation. cip

Our health coaches are trained in health coaching techniques that empower and motivate participants by advancing their willingness to change. It is a patient-centered approach that works with the participants agenda for change, rather than the health coachs.
The most important value that a health coach adds is time to listen. Sometimes it takes a couple of conversations to understand what is really going on with a member.The home-visit piece of the program is also of great value.We can assist in identifying triggers in the home, and providing information to the physician regarding the home environment has been very helpful. AL: What are some of the barriers that the health coaches face when working with patients with asthma? JT: Some of the more common barriers are medication compliance, where member cannot afford medications. Nurtur contacts the physi December/January 2009

Reprinted with permission from Case In Point Magazine All rights reserved 2009